The clear joint message from speakers was that there is a deep need for increased collaboration between stakeholders throughout the healthcare industry and related investigative services to effectively tackle this problem, which is slowly crippling the industry.

“Fraud represents a material threat to the affordability and sustainability of medical schemes and also for any future National Health Insurance (NHI) initiatives,” said Dr Gregory Pratt of Medscheme’s forensic unit.

Dr Pratt added that if something isn’t done soon the affordability of schemes will reach a tipping point that will place too much economic pressure on young and healthy members, causing that essential supporting element of the industry to leave schemes and potentially collapse the industry.

Among some of the reasons given for the increase in fraud and irregular pricing, Dr Pratt pointed to practitioners having a sense of entitlement in charging inflated amounts around Prescribed Minimum Benefit (PMB) cases, the infiltration of organised crime syndicates into the healthcare industry because it presents a soft target, and a desire to meet certain lifestyle aspirations.

Special Investigating Unit (SIU) Head, Adv. Andy Mothibi, highlighted the importance of establishing methods that will bring together all possible stakeholders within the healthcare sector in order to tackle the issue and accelerate investigations into practitioners facilitating corrupt activities, emphasising the role played by “whistle-blowers” in the success of such investigations.

Mothibi highlighted that the SIU is looking to “whistle-blowers” to continue providing information to the Unit in order to tackle fraud, waste and abuse. He proposed that there is a need to take investigation and prosecution proposals directly to the State President to be signed for approval. From there the entire process would be enabled through direct collaboration with numerous agencies across the board, including the Criminal Justice Agencies, Constitutional and other public oversight bodies, including the Public Service Commission, Public Protector, Parliament’s Standing Committee on Public Accounts (SCOPA), Independent Police Investigative Directorate (IPID), the Inspector-General of Intelligence (IGI) and The Competition Commission, and dedicated coordinating bodies in government, business, and civil society.

“Of importance is to ensure that anti-corruption efforts should create a system that can operate freely from political interference and can be supported by both public officials and citizens,” said Mothibi.

Mothibi highlighted that in order to address this, there is a need to “strengthen the multi-agency anti-corruption system, take a societal approach to combating corruption, strengthen protection of whistle-blowers, improve oversight over procurement procedures for increased accountability, empower the tender compliance monitoring office to investigate corruption and the value for money of tenders, create an open, responsive and accountable public service, and strengthen judicial governance and the rule of law.”

Proposed solutions

Dr Pratt urged stakeholders to utilise big data analysis technology to accelerate the identification of anomalous claiming patterns, allowing earlier and more decisive interventions, as well as to correct system vulnerabilities.

Dr Pratt also said there is a need to push for much stronger vetting when it came to matters such as the issuing of medical practice numbers – especially when additional numbers are issued to the same practitioner.

“We are seeing some healthcare professionals having as many as six practice numbers whilst operating from a single practice location. When a Scheme blocks a practice number due to confirmed fraud, the practitioner is currently able to obtain a new one with little difficulty,” said Dr Pratt.

Dr Pratt added that the fragmentation of the industry itself was contributing to its actual and perceived vulnerability to fraudsters, and proposed that industry stakeholders make a concerted effort to collaborate and share information, not only on fraudulent practitioners but also on preventative methodologies. The schemes will also be taking strong first steps in better utilising the services of agencies such as the SIU.

Mothibi called on the healthcare industry to “fight the scourge together,” in order to realise the SIU’s stated goal of “zero corruption tolerance” by the year 2030.

“We know this will not be an easy challenge, considering that sub-Saharan Africa currently sits at the bottom of the Corruption Perceptions Index, but by systematically isolating problem areas, keeping abreast of the ‘evolving technological landscape’, and developing memorandums of understanding with bodies such as the Council for Medical Schemes (CMS), Health Professions Council of South Africa (HPCSA), and the BHF, the goal is attainable,” said Mothibi.

Using the anticipated procurement activity within South Africa’s NHI as an example, Mothibi emphasised that establishing collaborative mechanisms such as those memorandums is a matter requiring haste.

In dealing with problematic practitioners, the Zimbabwean model of a filtering process may be of use, suggested Douglas Gwatidzo, of CIMAS medical scheme in Zimbabwe.

“In Zimbabwe before issuing a practice number, local authorities visit facilities to ensure that the facilities meet the basic requirements, then the Health Professions Authority (HPA) also does so, and finally the medical schemes themselves are given the opportunity to assess the facilities and give constructive feedback to the HPA on any negative issues they may have missed – which has itself in some cases actually led to the closure of problematic facilities,” said Gwatidzo.

Weighing in on the issue, President of the HPCSA, Dr Kgosi Letlape, said: “I am not happy we are paying people who are manipulating the system on our register. We need to go back to basics, and review the process of issuing practice numbers. BHF has a big role to play in addressing this.”

“We also need to revise the regulatory framework. Administrators must take more stringent measures to make sure that what health practitioners claim is correct, and where there is suspicious activity, administrators must request proof from practitioners to show that people were sick, and contact members to make sure that they were actually consulted. Where suspicious activities are found, rather administrators withhold funds initially than pay out, as the prepayment systems seems to open opportunity for fraudsters,” concluded Dr Letlape.